Then I came upon a striking post called Live Each Day Like There’s a Lot of Them Left, dated August 2. Jen Singer, a blogger with two sons and a history of lymphoma, expresses the considered notion that maybe the best thing to do after cancer is to live, essentially, as you would do otherwise, except with a bit of added balance.

She writes:

… I — the one who has been so close to the end of life – am supposed to tell you to treat each day as though it’s your last. Except, if it were my last, I certainly wouldn’t be tanking up my mini-van for the rest of the week’s carpools…

Rather, I suggest that you treat every day as though you’ve got a whole lot of them left, precisely because you don’t really know if you do. Go about the everyday, do the drop-offs, get out the knots. Clean the house. Go ahead and get through the stuff that fills your To-Do list…Slog, if you must, because that’s perfectly okay…

Still, every now and then, don’t forget to turn up the radio and listen…

Her point, I think, is that we all have to move on with our lives if we can. It’s the nitty-gritty, mundane activities that keep families on track may also keep us sane, safe and sound. Cancer can be liberating, but that doesn’t necessarily mean we should exploit that as license to escape from responsibilities.

The pressure to “treasure each moment” can be counterproductive. To live life as usual is a challenge of another sort, important for the normal development of our kids and ourselves.

I like this perspective.

Like Jen, I take pleasure in the ordinary stuff – cooking, helping my family and yes, checking off items on the list of things I’ve been meaning to do for years. It’s a long list, and I’ve lots to take care of.

Last night I stayed up to watch the first episode of Laura Linney portraying a middle-aged woman in a new series called The Big C. The story is that she’s got a teenage son and a recently estranged, overweight husband who loves her. She lives in a suburban house that could use some work. She teaches in a high school. She has a brother who’s deliberately homeless.

Her name’s Cathy – how ordinary can you get? Well, Cathy recently found out she has a terminal case of melanoma. In a change of pace, she expresses herself freely and does pretty much whatever she feels like doing.

For me, this TV situation has some big draws:

Laura Linney‘s a fine, not uninteresting actress. A few years ago she played a charming Abigail Adams in a history-minded miniseries. But I couldn’t bear to watch her miscast counterpart, Paul Giamatti, pretending to be President John Adams, so I didn’t. As in the storyline of the Big C, here’s an opportunity for Linney to shine.

Gabourey Sidibe, a young obese woman who stars in the movie Precious, may or may not be a fantastic figure on film or TV. She’s yet to be established beyond her debut and after watching last night’s episode I’m concerned already that she’s being “used” as an object for the protagonist’s preterminal beneficence. Still, she’s a definite plus.

The Big C‘s plot includes at least two “atypical” and potentially complex features. First, Cathy chooses not to take chemotherapy or other treatment. This intrigues me, and may be the show’s most essential component – that she doesn’t just follow her doctor’s advice. Second, she doesn’t go ahead and inform her husband, brother or son about the condition, at least not so far.

We’ve seen this non-communication before in movies (Susan Sarandon in Stepmom, for instance) and in real life, for most of human history. It’s too-easy for a blogger-patient-oncologist to forget that not long before our Facebook era, most people didn’t talk much about having cancer and even today, many patients prefer not to do so. Norms change.

If the point of the Big C is to broaden the dialog on cancer and talking about cancer, that’s worth a lot, still.

What’s wrong with the program? I think the doctor has some brushing-up to do about his image. He’s 31 and Cathy’s his first “case” – all of which is credible, but with the exception of an x-ray briefly revealed on the wall-mounted light-box, it’s not clear if he’s an oncologist or a dermatologist somehow offering her chemotherapy and pamphlets. His white coat is too short, in the style of a medical student’s. He uses few polysyllabic words. He looks well-rested and neat. In one strange scene, the patient and doctor meet for lunch at a pleasant outdoor restaurant. That’s not how oncology’s practiced, at least as I know it.

But I’m learning, too. And I’m wondering about the informational content of the doctor’s slick handouts, about which the protagonist, Cathy, has a vision.

This is an easy post with a simple message. Maybe it’ll even help some people.

Earlier today, in the midst of a deep water exercise class, I remembered that I needed to call my eye doctor before the weekend. You see, I’ve been meaning to get a new pair of glasses and it doesn’t make sense to get those without a current prescription. Then I realized that I hadn’t been to see her in two years. Time flies –

Like many people, I’ve been carrying around a mental stack of offices I’ve been meaning to call. So instead of taking care of some serious writing for a book proposal, that I really need to do, I ran the list:

It turns out that late summer is a great time to call medical offices for routine appointments. (Sorry secretaries, I know the doctor’s vacation is when you tidy up, even electronic paperwork and filing.) But seriously, someone answered the phone promptly or readily returned my call today. What’s more, I beat the post-Labor Day rush for adult doctors’ visits.

A few months ago I wrote that I’d take another look at Nurse Jackie, a ShowTime series about a drug-addicted ER nurse and mother. The posters, featuring Edie Falco as the program’s heroine, caught my eye; she’d charmed me in her previous role, as Carmela Soprano. Besides, this story’s set in NYC. The hospital is vaguely-modeled upon St. Vincent’s Medical Center, a recently-shuttered Catholic Hospital in Greenwich Village.

Out of some sense of compulsion, wanting to provide careful follow-up to my readers, I forced myself to watch each episode before completing this review. Unfortunately I found the series so unpleasant, besides uninteresting, that it took me months to plod through my assignment.

Jackie is supposed to be a crackerjack nurse who has some serious problems including drug addiction. That premise might be fair enough, in a House-like way, if her life-saving skills had unique value. But they don’t: the underlying problem with this show is that Jackie has no exceptional or redeeming qualities as a nurse. Sure, she cares about some of her patients, but that’s nothing extraordinary. Rather, she stands out by lying, making up results and, not infrequently, cutting out when and where she’s needed.

The emergency department where Jackie works is supervised by a not-quite indifferent administrator portrayed disappointingly by Anna Deavere Smith, whose real talents reach far beyond the realm of the petty disputes and not-unusual life issues that plague this TV hospital’s staff.

As a physician-blogger who’s trying to understand the potential value of Twitter in health care, I thought perhaps I might learn from the show’s ER doc Cooper’s social media skills: he tweets while working, nominally as a physician. But he’s presented as such a vain, stupid twit that he’s just not credible as a doctor of any kind. Even his Tourette’s tics are adolescent – he grabs women’s breasts when stressed, a curious behavior that seems, if anything, to suit the show’s shallow drama more than any real patient’s disease.

Plenty of TV shows have offered insights on health care delivery by quirky, self-absorbed and sometimes-deluded workers with interpersonal issues and stress (think M*A*S*H, for starters). But this series doesn’t make that grade. There’s no adult humor, no attempt at medical mystery-solving or even a good, old-fashioned medical ethics quandary. Unlike the Sopranos‘ story, here most of the characters bear little depth. Jackie’s multiple psychopathologies are a vile, exaggerated example of a woman juggling too many things, badly.

So I was surprised to find out that Jackie’s contract was renewed. Even more, I wish that the real St. Vincent’s Hospital, which once provided care to me and, over the years, helped countless other real New Yorkers, were still open.

I won’t revisit this show. But I’m looking forward to The Big C, which starts on Monday. Hopefully that will deliver better entertainment, or at least some fresh ideas.

I hope this post will be the start of a long conversation on breast cancer survivorship. The question is, what’s the right, PC and emotionally-sound, sensitive but not sappy term to describe the situation of a person who’s living after breast cancer?

Some might say, who cares if you’ve had it?

Once, about six years ago, a colleague – an oncologist in my community – I met on the street stopped and asked me how I’d been. I said, well, I’d been out for a while because of some health problems. I mentioned that I had breast cancer among other things. “Who doesn’t have breast cancer?” she quipped, and then we talked about medical offices.

So what? was her point.

Sure, everyone’s got stuff by the time they approach their 50th birthday. Life would be pretty boring if we didn’t. And my personal history happens to include BC.

OK, NBD.

Why it matters, at least in my situation, is that I’m writing about health issues including breast cancer. So I think it would be deceptive to not mention this loaded “credential.” In a few weeks I’ll be teaching med students again, and although I don’t think that episode of my life is central to my capability as a teaching physician, I do think (and hope) it makes a difference.

Thinking more generally:

A lot of women, me included, have major physical changes upon undergoing treatment for BC. My hair was curly for most of a year. My breasts are gone. My bones are thinner and I’m estrogen-deprived. Sound depressing? It is, for as many as 30 to 40 percent of women at some point after their diagnosis. It’s not a minor experience in the physical, emotional or life-changing sense.

TV aside, the problem with the “survivor” term is that, maybe, it implies some sort of heroism or strength. But as an oncologist who happens to have had good insurance, knowledge and friends in the field, I just see it as, largely, the luck of the draw: there’s no reason for me to survive while another woman struggles and succumbs to metastatic disease.

I can’t deny to my readers, family, friends and others that I’ve had breast cancer, because it does affect my writing, feelings, capabilities and outlook. But I wish there were a better term for my status.

Kudos to my newest doctor, a dermatologist whom I met yesterday for evaluation of a small, benign-appearing mole I recently noted on my right leg. What she did right:

1. She saw me promptly, at the time of my scheduled appointment.

(Thank you, you seem to value my time, as I do yours.)

2. In her initial clipboard-bound paperwork, along with the usual forms about my history (always with insufficient space for my case and, unfortunately, still non-electronic) she asked not only for emergency contact information, a standard, but for the name and relationship of someone besides me – such as a family member or close friend – with whom she might discuss my condition, if I permitted.

(Thank you for asking this and really, I’d prefer that you not speak with my parents about my results. I’ll be turning 50 next month.)

3. In the same short set of greeting paperwork, she didn’t just ask for my phone numbers and other contact information. She took this to another level and asked if it’s OK to leave a message on my home’s answering machine.

(Thank you again, for asking. I have teenage sons and don’t particularly want them hearing about my appointments or biopsy results before I get the message.)

4. Her assistant walked me into a room and told me to stay dressed. “The doctor likes to talk to people with their clothes on, before they put on the gown,” she explained.

(This was really terrific, and I hadn’t even yet met the doctor!)

I wasn’t disappointed: when Dr. G. entered the room, she was professional, considerate and thorough. I got the feeling she works conscientiously and carefully. And that she cares.

——

I can’t help but reflect on what a difference these sorts of details can make in a patient’s experience. How many times had I been in an orthopedist’s office for the first time, or at a different dermatologist’s, pleading with a nurse or technician that I might keep my clothes on until I’ve met the doctor and we’ve spoken.

It’s inefficient, I suppose, for doctors to meet patients in a small exam room, to exit and then re-enter after they’ve changed into a gown. But it’s humiliating, I feel, for an adult woman or for any person to meet the physician, especially for the first time, when they’re not wearing clothes.

A dermatologist, or any doctor for that matter, can’t necessarily take away the condition you have, which may or may not be serious. They may not have an easy remedy. But if they treat you with courtesy and respect, that makes it easier to cope with any situation.

Fortunately the lesions Dr. G. removed are likely nothing more than benign moles with Greek-derived names. One was a bit vascular. The lesion bled once she snipped it off, and so I can’t swim for a few days until the wound heals. But otherwise I’m doing fine.

A prominent article in yesterday’s New York Times considers some troubling problems regarding inaccuracy in breast cancer diagnosis and pathology. The main point is that some women get needless, disfiguring and toxic treatments after being told they have breast cancer when, it turns out, their condition was benign.

My main take on this situation – which doesn’t just apply to breast cancer – is that, whenever possible, patients should get a second opinion on biopsy results before undergoing major treatment. The costs of a second pathology review is sometimes covered by insurance, but sometimes it’s not; either way, that’s money well-spent, especially if the opinion is rendered by an appropriately-credentialed, expert pathologist who works in a state-of-the-art facility.

From the doctor’s perspective there’s responsibility, too. Surgeons shouldn’t lop off a woman’s breast without knowing that the pathology is real. Well-trained oncologists know they’re supposed to review the pathology, to make sure the diagnosis is true, before giving chemo. The Times story indicates that the Cancer Treatment Centers of America has a specific policy in this regard, that doctors there must review the pathology for patients who are new to their system. This wise policy, common in some hospitals and tumor boards such as where I practiced, makes it less likely that oncologists or other doctors will give inappropriate treatment.

From an administrative standpoint, there could be better regulation to assure quality. Pathologists who are employed, busy evaluating tumor specimens without supervision, should be board-certified and required to be up-to-date in the specialized fields of their practice. And laboratories (as opposed to pathologists who work there) should be closely monitored because pathology errors can arise from faulty stains, use of poor-quality or old reagents, incorrect calibration of a machine, lack of appropriate “controls” for each batch of cases evaluated, etc.

A related story appeared earlier this year, also in the Times, on the variability of pathology reports. That article reported on how different pathology labs provide disparate results on whether a breast tumor has estrogen and progesterone receptors in the malignant cells, and whether the malignant cells express Her2 – the target of Herceptin – or not. The lack of agreement among pathologists renders treatment decisions difficult. The piece focused on a physician who couldn’t decide if she should take Herceptin or not, because she received conflicting reports about her tumor.

Getting the diagnosis right underlies many cancer care problems and undue costs. If I were an insurance company executive, I’d recommend that my firm cover the costs of a second pathology opinion in all cases. It’s far less costly to find out that a “tumor” is not really malignant than to pay for surgery, chemotherapy and radiation that’s not needed.

Better still, I’d insist that biopsy specimens be evaluated by pathologists who are trained in current methods and who work in trust-worthy laboratories.

Such a policy would reduce false positives in cancer diagnosis, and would thereby reduce the toxicity and costs of unwarranted cancer treatments. With better diagnostic facilities, those patients who do have cancer would not be so afraid to undergo the treatments they really need, because they’d be confident that they and their doctors were making decisions based on reliable information.

Hiking, or even just walking, in the hot summer heat to see ancient ruins, national monuments or spectacular vistas can sap the energy of healthy people. For someone who’s got a health issue – like chronic lung disease, reduced heart function or anemia – or anyone who’s pregnant, elderly or just frail, summer travel can knock you out in the wrong sort of way.

Slowing down is not something that comes naturally to me. I’m always eager in sightseeing and keen on keeping up with my teenage sons; learning to pace myself and insisting that they go ahead uphill or down into a cave, without me, has not been easy for any of us. But after a few episodes of stumbling, lightheadedness and exhaustion so severe that I had to cut out of museums I’d traveled across the world to see, I’ve adapted a prophylactic, healthy approach to summer visits to remote places:

1. Don’t plan too much for any one day.

This means you may have to forfeit some activities and sites you’d like to see. Just as, while vacationing, some parents plan for “down-time” for their kids by a pool or beach, adults should set aside time each day for resting in a shady place.

2. Plan visits to hot sites in the early morning or evening.

Museums can provide terrific respite from the midday heat. Theaters, shopping malls and modern hotels are all fine places to wait out the sun’s peak.

3. Drink lots of water.

Depending on where you are traveling, this may require that you buy bottled water. Fake mineral water is rare, but you have to watch carefully for it by checking that the bottle cap is properly fastened.

(The movie Slumdog Millionaire includes an instructive and unforgettable take on this tourist’s nightmare; one scene depicts children systematically sealing plastic caps onto bottles of tap water in an unnamed, Mumbai restaurant. The film’s medical lesson: try to avoid buying beverages in places that seem untrustworthy.)

Keep in mind, restaurants usually wash and rinse the glasses with tap water. So if the tap water’s no good, drink your beverage straight from the bottle. And, if that’s the situation, don’t put dirty hands or fingers at the bottle’s opening because that’s where you’ll put your mouth.

4. Skip the ice if you’re not sure the water’s safe to drink.

If water or another beverage is served with ice in a glass, send it back. At some risk of seeming pedantic, I’ll repeat what my mom taught us while traveling: tap water is not safe to drink just because a hotel or restaurant proprietor says so. Rather, trust in your good judgment and common sense.

5. Bring tissues to handle bathroom doors.

Drinking fluids may lead to increased urination, which means you may find yourself in unclean restrooms that may not even have running water. Here, the most important thing is to avoid touching the toilet or any sink-handles or knobs with your hands.

6. Take time to sit and rest periodically.

Walking and standing for long stretches can cause back pain and fatigue. So even in a museum, typically a comfortable kind of place, whenever I spot a bench I’ll sit there for a few minutes. While out in a city, I might stop and buy a cup of tea at an inexpensive restaurant just for the purpose of sitting, or get on the bus just for the opportunity to take a seat.

—-

I find that if I pace myself, which means admitting that I can’t necessarily do all I’d like as fast as I want, I can see the world!

I learned of a new study implicating stress in reduced breast cancer survival by Twitter. Three days ago, a line in my feed alerted me that CNN’s health blog, “Paging Dr. Gupta,” broke embargo on the soon-to-be-published paper in the journal Clinical Cancer Research. It seems the story – that women who undergo a stress relief program live longer after breast cancer recurrence – couldn’t wait.

“Less stress helps breast cancer patients” is the title of the rushed post. What the researchers, based at Ohio State’s Comprehensive Cancer Center, report is that psychological intervention helps to increase the quality of life and survival among women with recurrent breast cancer.

The intervention at issue is this: weekly, small-group meetings of BC patients for 4 months after their initial surgery and diagnosis. Led by clinical psychologists, the women met 18 times and discussed strategies to reduce stress, improve mood, strengthen social networks, eat better, exercise and adhere to medical treatments.

The current report is an extension of previous findings among an initially larger group of women at the time of BC diagnosis. Then, the researchers randomized 227 patients after surgery, all with stage II or III disease, either to receive the intervention, or not, after an initial psychological assessment and blood tests to check their immune function. The women were overwhelmingly Caucasian, mostly with stage II tumors, well-educated and, for the most part, had ER/PR+ tumors. What the researchers noted was that:

In 2008, the same Stress and Immunity Cancer Project investigators reported in the journal Cancer that the psychological intervention reduces BC recurrence and prolongs survival. Here’s where the results become both exciting and suspicious. In 2007, with a median follow-up of 11 years, 62 women (29%) in the initial study had recurrent disease. The proportion among those who’d received the intervention was indeed lower, confirming the authors’ hypothesis that the intervention would help prevent BC from coming back. But the p-value for this difference was 0.034, barely meeting the threshold for statistical significance. Similar results were observed for overall survival among the women who’d attended the group sessions: they had a reduced risk from death with a minimally-significant p-value (0.028) for the difference.

Now, the Ohio group reports on the 62 patients who relapsed. Before going further, I should say that it’s a bummer of a result from a medical perspective and from mine as a BC survivor out at seven years. Group support aside, 44 (71%, yikes!) of the patients with recurrent disease have died with a median time until death (after recurrence) of 2.8 years (range: 0.9 – 11.8 years).

What the authors conclude is that the psychological intervention improved survival after BC recurrence. How the data flowed is this: among the recurrences, there were 33 women who’d been randomized to the assessment only, “A” arm of the original trial and 29 who’d been randomized to the intervention, “I” arm. These numbers were whittled down to 18 patients who could be followed for continued study on the “A” arm and 23 women on the “I” arm. So the total number of women evaluated in this new report is small: just 41 women.

Among those, the women who received the psychological intervention were more likely to survive, with what’s called a hazards ratio of 0.41. Here again the p-value is valid but marginal (p= 0.014). The authors show a very limited amount of data regarding test-tube based studies of natural killer (NK) and T lymphocytes in the different patient groups, and suggest in the paper’s abstract that “immune indices were significantly higher for the intervention arm.”

What would have killed this paper (pardon the verb) had I been a reviewer is this: among the 41 women with recurrent disease, there was a major difference in the treatments they received. According to the “Patients and Methods” section of the paper, in the section on “adherence, chemotherapy dose intensity,” the authors indicate that just 6 of the “A” patients received chemo in the 12 months following the recurrence, while 13 of the “I” patients got chemo in the same period.

My math: only 6 of the 18, or 33 percent of the “A” group (assessment-only) patients received chemo, while 13 of the 23 (56 percent) of the “I” (intervention) patients got chemo in the year after recurrence. That’s a huge difference in medical treatment among a very small number of patients.

My point: the small difference in survival after recurrence among those women who received structured psychological support, years earlier, may be attributable to the prompt chemotherapy they received upon relapse of the cancer. This seems a more plausible explanation than that group therapy-type sessions make a difference in tumor biology or treatment resistance. (Neither outcome is proved by this study.) The difference may also derive from better overall health in the women who initially received the intervention that included advice and support regarding diet, exercise, smoking cessation and medication compliance.

My opinion:

I think there can be tremendous value in psychological support for people with illness of any kind, whether that’s provided casually by supportive families and friends, one-on-one psychotherapy, medication and/or group meetings. And it’s easy to envision that meetings in which women with similar disease situations and concerns get together and discuss coping mechanisms, how to stay healthy, eat better and exercise could have positive effects on overall survival.

But the immune benefits of stress relief, like those presented in David Servan-Schreiber’s like-minded Anti-Cancer, are bogus. There’s no scientific evidence that the sort of NK or T cell changes tested in this study help or hurt breast cancer growth. It’s possible that a revved-up, stress and steroid-driven immune system might help kill cancer cells, or might favor their expansion. It could go either way. The effects of stress steroids on tumors vary and are complex. Prednisone and similar steroids, for example, which resemble the body’s natural stress steroid cortisol, are well-established and effective components of most lymphoma treatment regimens and once were a mainstay of breast cancer treatment. My point is not that the immune system doesn’t affect tumor growth. (I think it can and does.) But the effects are complicated and differ among individuals and according to the specific tumor type.

On linking stress and breast cancer: this argument, which is all that it is in the absence of better data, is patronizing and demeaning to women. It’s the kind of advice we offer children, that if they think and do the right things the outcome will be favorable. Oncology doesn’t work that way. If a woman’s breast cancer comes back, it’s not because she didn’t go to support groups or relax sufficiently. Tumors grow due to inherent, malignant properties of the cancerous cells and other biological factors in the body, such as other illnesses that may, indeed, weaken the immune system or limit a person’s capacity to receive effective treatment.

I’m all for stress reduction, as an aim in itself. But it’s not a cure for cancer.

Yesterday I visited my internist. I had no particular complaint. My back hurt no more than usual. The numbness in my left foot was neither better nor worse than it was last month. I wasn’t suffering from vertigo or abdominal pain. I went because I had an appointment to see her, nothing more.

Until just a few years ago, I rarely visited a doctor unless I was pregnant or sick. I called when there was a problem, and my doctor would see me in whatever unusual circumstances I was in. She checked on me when I was in the hospital, reviewing my labs and x-rays and whatever else there was to take in. When I had cancer, or needed pre-operative evaluations for surgery, she would check my heart and lungs and write a note as needed. Sometimes I went to her office for a flu shot.

The idea of an adult woman seeing the doctor for regular, what some might call “well,” care might seem strange or even wasteful. Some might consider it a luxury, which I suppose it is.

But I think some of the most informative doctors’ appointments are routine. That’s because there’s value in a doctor’s getting to know a patient when she’s not particularly ill, when she’s not in pain or terrified, when she’s feeling just as usual.

I’ve had the same primary care physician since 1987. She knows my habits, my fears and my quirks. She, as much as anyone, has a sense of how I’m doing – emotionally and physically. In some years, I’ve taken better care of myself than in others, and she’s very much aware of that. She examines me carefully and makes suggestions regarding diet, physical therapy and other everyday, non-urgent matters in my life that affect my health.

The best thing about having a doctor know me so well is a matter of trust. I rely on her not to solve what’s unsolvable, which of course no one can do, but to do the best she can to take care of me. If ever I’m very sick again, in a circumstance when I can’t make decisions for myself, I know she’ll act according to my interests. She’ll be able do so because she knows me, my usual self.

Having a doctor who knows you shouldn’t be a privilege. Really I wish it for everyone. It helps.

Nurse Jackie’s back on TV tonight. I know this because when I logged on to the New York Timesthis morning her ad flashed right at me, front page and right center. She’s displayed prominently on Huff Po, vanishingly on Dictionary.com. With just a quick search I can’t find her anywhere in the Wall Street Journal. At the LA Times she takes over the screen.

Poster for Nurse Jackie, Season 2

(As an aside, on the shifting nature of medical information, most future readers of this post will not know for sure if what I’ve described about the present on-line positioning of these commercials for TV is true. The same happens in practicing medicine, when clear signs of disease – like abnormal crackles on a lung exam – can be fleeting, leaving no digital or even a film imprint, yet very real. So you’ll have to trust me, or take no value from this depiction.)

For the “facts” on Nurse Jackie you can find her on Showtime’s original website. There, the program promises to continue “its look deep inside the complicated heart and soul of a functioning addict, a loving wife, mother, and a first-class nurse.” I’m curious but must admit that last year I watched only part of one episode and didn’t return.

Back then I was turned off preemptively by the image of Edie Falco looking harsh, white-coated and unsmiling. The syringe and needle in her raised, gloved hand suggested a third finger, or at least that’s how it seemed as we drove past her image, repeatedly, on a giant billboard. That poster was enough for me. I’d spent too much time in hospitals in trust of innumerable nurses to want to see that side of health care delivery.

But today she beckons, half-smiling, an aura of pills and syringes above her head. Maybe she’s happy about the health care reform bill’s passage last night, but I don’t think she could have known about that when the photo was taken, or in her TV unreality world, that legislation matters. What’s clear is that Nurse Jackie looks warmer, tired maybe from her work. She’s appears ready to help someone, a stethoscope slung over her neck. Her right arm is raised, like in last year’s pose, but gentler, calmer. It’s no accident the poster heralds a “Holy Shift.”

Back to reality –

This morning I was listening to WNYC while reading the newspaper and eating my healthy breakfast. As I recall, according to a reporter assigned to assess the public’s and health care workers’ response to the health care reform bill among people on the street near Lenox Hill Hospital, in my neighborhood, one individual said she doesn’t really know what to expect from the changes because she gets most of her news from TV. I didn’t catch any more details – if she meant CNN, for example, or Fox or The View – and exactly how and why she found the source limiting.

One thing I did note in the Times, and also on the Kaiser Health News website, both of which provide excellent summaries of the hopefully-real health care changes to come, is that reform won’t even start to happen for the most part until 2014. Meanwhile grows an authentic addiction to the Internet, TV, radio and even some blurry advertisements for information on medicine that people can’t or don’t get elsewhere.

So I’m thinking I should watch Nurse Jackie tonight. Give it another try. Maybe I’ll learn something. And whatever did happen to the House of God?

A study published on-line this week in The Journal of Clinical Oncology (JCO) suggests that regular, low-dose aspirin use reduces the risk of recurrence and death from breast cancer among women who’ve had stage I, II or III (non-metastatic) disease.

This is a phenomenal report in three respects:

1. The dramatic results: among women who’ve had breast cancer, regular aspirin use is associated with a reduced risk of recurrence and death from cancer by more than half;

2. The relevance; these findings might affect millions of women living after breast cancer, today;

3. The cost: aspirin is widely available, without patent restriction. Aspirin costs around $5 for 100 tablets, several months’ supply.

About aspirin:

First, a concern that’s cited in the report:

Aspirin is an old and generally safe drug, available over the counter, that can be very dangerous in people with have bleeding problems or low platelets (blood clotting cells). Among women with breast cancer who are actively undergoing chemotherapy, radiation and some other treatments, aspirin use can exacerbate bleeding problems and may be inadvisable.

Anyone who considers taking aspirin should discuss, first, with their doctor if it’s OK.

The study participants reported taking aspirin (acetylsalicylic acid, or ASA in medical parlance) at varying doses and for a variety of reasons. More than a third of the breast cancer survivors used aspirin for heart disease. In that scenario, the typical dose is a baby aspirin (81 milligrams) on most days. Other women reported they took the drug for muscle and joint pains, backaches, headaches and other reasons.

About the study:

The work derives from the Nurses’ Health Study, a three-decades-and-going-strong observational analysis of health among over 238,000 registered nurses.

This particular analysis hones in on 4,164 of those nurses who had non-metastatic breast cancer (BC) found between 1976 and 2002. The investigators monitored these post-breast cancer patients with periodic questionnaires until the time of their death or 2006. It’s a large study, involving some 45,139 person-years.*

About the findings:

Figure 1. Aspirin Use and Relative Risk of Death from Breast Cancer

Aspirin Use, Relative Risk for Death from Breast Cancer

These graphs represent data from “Aspirin Intake and Survival After Breast Cancer,” JCO, Holmes, et al, published on-line 2/16/10. The data are listed in Tables 2 and 3 of the paper, multivariate analysis, with 1.0 as the relative risk for women who had breast cancer and do not take aspirin (ASA).

Figure 2. Aspirin Use and Relative Risk of Breast Cancer Recurrence

Aspirin Use, Relative Risk of BC Recurrence.

Among BC survivors who reported taking aspirin between 2 and 5 days per week, the chances of dying from breast cancer were 29 percent relative to the baseline (no ASA) group and the odds of BC recurring, 40 percent. In other words, aspirin use was associated with a 71 percent decline in deaths from breast cancer and a 60 percent drop in the recurrence rate for these women.

For those who ingested aspirin 6 or 7 days per week, the effects were similar: the death rate from cancer was 36 percent and the recurrence rate 57 percent, both significantly reduced in comparison to women who didn’t use aspirin. Among survivors who used 0-1 aspirin tablets per week, there was no measurable effect on either breast cancer recurrence or survival.

The results applied pretty much across the board – to premenopausal and post-menopausal women, to those with Stage I, II, and to a lesser extent, Stage III disease and to survivors with estrogen receptor positive (ER+) and negative (ER-) tumors.

The findings were not anticipated, according to the investigators, because earlier studies failed to show that aspirin prevents breast cancer from developing in the first place. What’s different here, they speculate, is that aspirin inhibits some inflammatory molecules, like prostaglandins or cyclooxygenases. The authors suggest these enzymes promote growth and metastatic spread of tumors that are already present.

Some details:

The study statistics are sound, with good (low) p-values for the aspirin-use trends, meaning that the likelihood of the observations being due to chance is extremely low. There are some limitations: first that the trial was not randomized, and second, that the reported use of aspirin was based on survey data provided by the nurses. But the size of the study, involving more than 4000 women who had breast cancer, the duration of analysis (over decades) and the not-slight differences in results between the treatment groups speak to the significance and potential implications.

—–

*In this analysis, person-years would be defined as the sum, for all women registered in the study, of the years for which they’ve been monitored. For example if 3 women were evaluated, each for 10 years, the study would include 30 person-years of data.

I was tempted to write about Ethan Hawke, hematologist among vampires in Daybreakers, but gore’s not my favorite genre. A mainstream choice would have been Harrison Ford solving the enzyme deficiency of Pompe disease in Extraordinary Measures, but I didn’t get sucked in. I chose Precious, instead.

Poster for Precious, the film based on the novel “Push,” by Sapphire

This luminous movie relates to the practice of medicine everyday, big-time. Directed by Lee Daniels and based on the novel Push by Sapphire (Ramona Lofton), the film follows a very obese Harlem teenager who’s pregnant with a second child by her abusive father. She’s humiliated daily by her welfare-dependant mother who forces her to cook greasy food and perform sexual acts all-the-while telling her she’s worthless. She’s 17 years old and can’t read. Things can get worse, and do.

What’s relevant to medical lessons?

For doctors –

The message of Precious, that every human life has value, should be obvious to every person employed in the health care system. But I know too well that’s not true.

When I was a medical student in 1985, working with a team of surgery residents, we cared for an obese young woman from Harlem who came in with a life-threatening case of pancreatitis. Her internal insulin-manufacturing organ was so inflamed that her entire gigantic abdominal cavity was tender and bloody. During what seemed like an endless operation in the middle of the night I stood and held firmly a retractor as best I could. The next morning and thereafter, when we made rounds, the residents called her “the whale.”

I learned a lot about pancreatitis and surgery that month. But I couldn’t understand how she, my patient, tolerated the team’s attitude. She didn’t seem to mind, perhaps because we saved her life and the care we provided was free. In retrospect, I wonder if maybe, like Precious, she was too-accustomed to disrespect.

Of course, this is an extreme example from 25 years ago. And I know from my experience working for years in a hospital, and in my years as a patient, that most doctors treat most patients with appropriate dignity. But those residents I worked with then are senior practicing physicians now, likely some on the faculty of medical schools. The disposition to disparage patients, more often subtly – in keeping them waiting without good reason, in dismissing their long lists of real concerns, in somehow putting ourselves above them and even, still, occasionally expressing frank contempt for some unfortunate souls still permeates the hospital culture.

For patients –

When Precious is abused, her mind runs elsewhere. She imagines herself, huge body and all, cast glamorously among television stars or dancing with popular singers. She pretends that she’s all right even when she’s not, really. Finally she speaks up for herself, telling a social worker about her predicament.

Ultimately that’s what makes the difference – her confidence in the value of her own bruised life. She recognizes that, despite everything, she’s a full-fledged human deserving better and has the guts to ask for help. By insisting, by knowing, that her life matters, she pushes herself out, if only partly, from the bleakest of circumstances.

If you’re disabled, hurt, wounded, damaged – ask for help when you need it. Respect yourself, as Precious did. That sends a signal to doctors that you value your life, and they should treat you accordingly.

Mrs. Henrietta Lacks died of metastatic cervical cancer in the colored ward at Johns Hopkins Hospital in Baltimore, MD in September 1951. She lived no more than 31 years and left behind a husband, five children and an infinite supply of self-replicating cancer cells for research scientists to study in years to come.

HeLa cells with fluorescent nuclear stain (Wikimedia Commons)

Like many doctors, I first encountered HeLa cells in a research laboratory. Investigators use these famous cells to study how cancer cells grow, divide and respond to treatments. I learned about Mrs. Lacks, patient and mother, just the other day.

Skloot chronicles her short life in fascinating detail. She contrasts the long-lasting fate and productivity of her cells with that of the woman who bore them. She connects those, and her human descendants’ unfortunate financial disposition, to current controversies in bioethics.

In the years following their mother’s death, scientists repeatedly approached her husband and asked her young children for blood samples to check the genetic material, to see if their DNA matched that of cell batches, or clones, growing in research labs.

The issue is this: her husband had but a third-grade education. The children didn’t know what is a “cell,” “HLA-testing” or “clone.”

The family had essentially no idea what the doctors who’d taken, manipulated and cloned their mothers’ cells were talking about, Skloot recounts. They thought the doctors were testing them for cancer.

Years later, when they learned that their mother’s cells were bought, sold and used at research institutions throughout the world, they became angry and distrustful. The problem was essentially one of poor communication, she considered.

“Even a basic education in science would have helped,” Skloot said. “Patients, they want to be asked, and they want to be told what’s going on.”

Waiting to see her, I sat in a floral fabric chair by a matching wood veneer coffee table strewn with worn magazines – Architectural Digest, Better Homes and Gardens and some old Time issues – I couldn’t help but think of how I was feeling seven years ago.

Then I was anxiously waiting to know my blood counts – the white cells, red cells and platelets – to see if they were sufficient for my scheduled chemotherapy.

That January, my white blood cells were so low that some doctors thought I should enter the hospital for IV antibiotics. (I declined.) My mouth was so full of sores I could hardly speak or eat. My hair was gone and I wore a strange wig. My right arm was broken (yes, I’m right-handed) so I couldn’t write or type. I was pale, weak with anemia and covered with bruises.

Chemo-brain, which I’d never learned about in med school, was just starting to set in. Before then, I’d always taken pride in keeping up with medical and science journals. But I could barely muster the energy to take a glance at those heavyweights. Even regular magazines appeared fuzzy, a scary symptom for an oncologist who knows too well that breast cancer cells can spread upstairs.

I wanted my next treatment. I wanted to get it over with, to put the breast cancer behind me.

After a while my oncologist stepped out into the waiting area and guided me to the hall by her office. “The cells are low,” she said. “We’ll have to wait another week, that’s all.”

I knew she was right. But a week seemed like a lifetime to me then.

I understood that giving chemotherapy suppresses the bone marrow, the body cavity where blood cells form. If my white cells dropped any lower, I’d be at serious risk for bacteria in the blood or invasive yeast in my mouth and throat. If the treatment reduced the red cell-forming elements in the marrow, I’d become more anemic. Already I was on a medication that affected the function of platelets, the blood-clotting cells. If the platelets fell further, I’d be at greater risk for bleeding.

I had no choice but to wait. So I did. The next week I got my treatment, and we were back on track, at least for a while.

Today, sitting in a similar chair, I calmly read the arts section of the newspaper and started working on the crossword. I’d tucked the New England Journal of Medicine into my bag, thinking I should read that, but it didn’t seem right. I wanted to remember what it’s like to be a patient who doesn’t know if she’ll make it through.

Several of my friends, mainly women, are affected now by cancer that’s spread. They go to see their oncologists regularly, and sit and wait for their blood counts, and sometimes get their treatments. Most hold undeniably upbeat, positive attitudes. But the reality is tough-going, day-to-day and month after month, with no easy end in sight.

How much easier it is to look back on a situation – a tumor – that was removed in an early stage. My cancer treatment wasn’t easy, but I don’t regret it for a second.

When my oncologist took me into her office today we chatted for a while and then she examined me.

As a trained hematologist (blood doc), oncologist and breast cancer survivor, I couldn’t resist checking this out. Here’s what I discovered:

The link traces to MommaSaid.net. Turns out MammaBlogger Jen Singer counts herself among lymphoma survivors in remission. Another mom in remission, I might add –

Jen clues us in on a new breast cancer awareness campaign that migrated to Facebook but three days ago – breast cancer awareness ? I updated my Status with my Bra colour ? and, as of this moment, has over 57,000 fans. Her solidarity with breast cancer patients and their loved ones is very real. She’s at increased risk, among other reasons for her sensitivity to the issue.

Jen plugs for greater public consciousness of other malignancies including tumors that arise from blood cells – conditions like non-Hodgkin’s lymphoma, leukemia and myeloma. She’s particularly concerned about a young neighbor, a teenager with recurrent leukemia, who needs blood now.

“So, I ask you this: Please put your blood type in your Facebook status and ask your friends to do so, too, to raise awareness for lymphoma and leukemia. Mine is O+, a blood type…

I was blown away by this, and impressed. What social media might do for the practice of hematology!

With just a few clicks at the keyboard and some thousands of on-line connections, one lymphoma survivor has improved the chances that one girl with leukemia will get the platelets she needs. And, maybe thanks to the Facebook blood typing information campaign, more potential blood donors will connect with those who need cells in the future.

False positives can arise during any of three conceptual segments of the testing process:

1. False positives occur during the test itself.

This happens when a radiologist inspects a film or digital image and labels the result as abnormal, but no cancer is present. This sort of problem is interpretive.

A common scenario goes like this – a spot in a mammography image suggests the presence of a possible tumor and the radiologist correctly notes that abnormality; later on, a doctor determines by sonogram, biopsy or another method that there is no malignancy in the breast.

(Other, uncommon problems in this category would include faulty equipment that reduce image quality, mislabeling or accidental switching of films; in principle, these kinds of errors should be non-events.)

If a clerk accidentally phones the wrong patient and tells her she needs another procedure because the results of her mammogram are abnormal, that call might instigate an untoward, false positive result. If the error is corrected early on, so that affected woman worries only for a period of hours and has difficulty sleeping for one night, she might experience some psychological and/or small financial cost from the matter. But if the mistake isn’t caught until after she’s had a sonogram or MRI, and consulted with a surgeon or another physician, the costs grow.

False positives also arise if a patient misunderstands a test result. An essentially normal mammography report, for example, might mention the appearance of benign calcifications. Upon reading that result, a woman or her husband might become upset, somehow thinking that “benign” means “malignant.” This type of false positive error, based in poor communication and lack of knowledge, can indeed generate extra doctors’ visits, additional imaging tests and, rarely, biopsies to relieve misguided fears.

3.False positives derive from errors or misinterpretation of results upon follow-up testing.

This category of false positives in screening mammography is by far the biggest, hardest to define and most difficult to assess. It includes a range of errors and confusion that can arise after breast sonograms, MRIs and breast biopsies.

3a. false positives in subsequent breast imaging studies such as sonograms and MRIs:

Many women in their forties and early fifties are premenopausal; their estrogen-stimulated breasts tend to be denser than those of older women. Reading their mammograms may be less accurate than for postmenopausal women. For this reason, a doctor may recommend a sonogram or MRI to further evaluate or supplement the mammography images.

These two radiology procedures – sonograms and MRIs – differ and, for the most part, are beyond the scope of this discussion except that they, too, can generate false positive results. A sonogram, for instance, may reveal a worrisome lump that warrants biopsy. MRIs are more expensive and sensitive; these tend to pick up subtle breast irregularities including a relatively high proportion of benign breast lesions.

3b. false positives in breast biopsy:

A breast biopsy is an invasive procedure by which a piece of the gland is removed for examination under the microscope. Sometimes pathologists use newer instruments to evaluate the genetic, protein and other molecular features of cells in the biopsy specimen. Years ago, surgeons did the majority of breast biopsies. Now, skilled radiologists routinely do a smaller procedure, a core needle biopsy, using a local anesthetic and a small albeit sharp instrument that’s inserted through the skin into the breast. Some doctors do a simpler procedure, fine-needle aspiration, by which they remove cells or fluid from the breast using a small needle attached to a syringe.

In principle, a false positive biopsy result would occur only when a pathologist, a physician trained to examine tumors at the cellular and molecular levels, misreads a case, meaning that he or she reports that the cells appear cancerous when they’re not. Fortunately, this is not a frequent issue in breast cancer diagnosis and management.

The real issue about false positives – and what may be the heart of the issue in mammography screening – has to do with how pathologists describe and define some premalignant conditions and low-grade breast tumors. This concern extends well beyond the scope of this tentative outline, but a few key terms should facilitate future discussion:

Lobular Carcinoma in Situ (LCIS) is not considered a malignancy by most oncologists, but rather an abnormality of breast glands that can develop into breast cancer.

Ductal Carcinoma in Situ (DCIS) is a Stage 0 breast tumor – a tiny cancer of breast cells that have not penetrated through the cells lining the ducts of the breast gland.

Indolent or “slow” tumors – The idea is that some breast cancers grow so slowly there’s no need to find or treat these.**

——

*This definition warrants some discussion, to follow in a separate post.

**As a physician and trained oncologist, I am uncomfortable with the published notion of some breast tumors being “so slow” that they needn’t be found or evaluated. I include these tumors only for the sake of completeness regarding theoretical types of false positive results upon screening mammography, as there’s been considerable discussion of these indolent tumors in recent news.

Slow-growing breast tumors are quite rare in young women. In my view, their consideration has no bearing on the screening controversy at it pertains to women in their forties and fifties.

——

As outlined above, the first two categories of false positives seem relatively minor, in that they should be amenable to improvements in quality of mammography facilities and technology; the third category is huge and where lies the money, so to speak.

The question of false positives in breast cancer screening – why and how these happen, how often these occur, and how much these cost, in physical, psychological and financial terms – remains a puzzle.

A few weeks ago the New York Times Magazine featured a piece on “Mammogram Math” under the heading “The Way We Live Now.” The author, a mathematics professor, argues that the risks and costs of mammography, though incalculable, outweigh the benefits. The paper printed the article along with a subtitle, “Why evidence-based medicine is actually right and scary” and later published three letters including one truncated response by me.

After a hiatus, I’ve rescanned the literature – just to be sure the question hasn’t been resolved in the past few weeks by a much-needed interdisciplinary team of health care policy experts, economists, statisticians, surgeons, radiologists, oncologists, nurses and for good measure, perhaps a few breast cancer patients and survivors.

There’s little published progress to report, aside from more hype and theoretical numbers such as I offered in a November essay. So I’ve decided to take the analysis a step further by outlining a tentative framework for thinking about false positives in breast cancer screening.

In a separate post, I will outline a proposed outline for categorizing false positives as they relate to mammography. Why bother, you might ask – wouldn’t it be easier to drop the subject?

Instead, I’ll answer as might a physician and board-certified oncologist who happens to be a BC survivor in her 40s:

To determine the damage done to women by screening mammography (as some claim and refer as evidence) we need establish how often false positives lead, in current practice, to additional procedures such as sonograms (fairly often, but the costs are relatively small), MRIs (less standard and more expensive), breast biopsies (scarier, slightly risky and more valued – how else can a pathologist determine if a woman with a breast lesion has cancer and, in the future, what type of therapy is best) or frankly inappropriate treatments such as chemotherapy for a non-cancerous condition (very damaging and the most costly of all putative false positive outcomes).

These numbers matter. They’re essential to the claim that the risks of breast cancer screening outweigh the benefits.

…The findings, published in the Archives of Internal Medicine, add to mounting evidence that Americans are overexposed to radiation from diagnostic tests, especially from a specialized kind of X-ray called a computed tomography, or CT, scan.

The risks of radiation from CT scanning will almost certainly add to the current confusion and concerns about the risks of breast cancer screening.

According to the American Cancer Society, a typical mammogram uses between 0.1 to 0.2 mSV per image. So even if multiple images are taken of each breast, the total dose remains under 1 mSV.

Another source, the Health Physics Society, estimates a dose of 0.7 mSV per mammogram. So if a woman were to have a screening mammogram every other year between the ages of 40 and 49, she’d receive approximately 3.5 mSV in total from those procedures.

By contrast, a single CT scan involves over a 10-fold greater amount of radiation (such as 8 mSV for a CT of the chest, 10 mSV for a CT of the abdomen) according to the Health Physics Society fact sheet.

2. Mammography is well-regulated by the Food and Drug Administration (FDA) and other agencies.

The Mammography Quality Standards Act (MQSA) requires mammography facilities across the nation to meet uniform quality standards. The law, first passed in October, 1992, requires all mammography facilities to 1) be accredited by an FDA-approved accreditation body, 2) be certified by FDA, or its State, as meeting the standards, 3) undergo an annual MQSA inspection, and 4) prominently display the certificate issued by the agency.

3. Women who undergo screening mammograms can control when and where they get this procedure.

Screening mammograms are elective by nature; a woman can choose an accredited screening facility and, in advance, learn something about its reputation and screening methods. Most women between the ages of 40 and 50 are capable of tracking their mammograms, whether they choose to have those annually, biennially, or less often.

Many CT scans are ordered for patients who are in the hospital – a very different sort of circumstance. Many hospitalized patients don’t feel well, don’t understand what’s happening to them and/or lack the needed assertiveness or language skills to ask about a scan before it’s done.

Summary:

Mammography is a relatively safe and highly-regulated procedure in the U.S. The recent news on risks from radiation in CT scanning should not confound the discussion of breast cancer screening.

from the National Center for Biotechnology Information (NCBI) database, http://pubchem.ncbi.nlm.nih.gov, accessed 12/11/09.

When I was a medical student, I studied some facts about doxorubicin hydrochloride, enough at least to answer a few questions during pharmacology exams. Later, as a resident in internal medicine, I knew the drug to be an anthracycline, a chemotherapy that intercalates into DNA, wreaking havoc in cells’ genetic material and reducing the replication potential.

As an oncology fellow, I prescribed and administered the clear, intense red fluid to patients with lymphoma and breast cancer. I learned to be careful: if the medicine slips from the intravenous catheter and enters the nearby, tender tissue below the skin, it can harm. The drug commonly causes hair loss and stomatitis; mouth sores can be so painful it hurts to eat, even when the nausea doesn’t squelch your hunger, or talk. Adriamycin affects the bone marrow, where blood cells are produced, and heart.

It’s not an easy drug; my patients knew this and so did I.

This month marks seven years since my first dose of Adriamycin, part of the “A/C” regimen that’s sometimes given to breast cancer patients. Was it worth going bald, getting anemia, sluggishness, mouth sores, chemo brain and all else that I experienced? Yes; I have no doubts. But I was lucky; my tumor was small and I needed only a few cycles.

I never knew Adriamycin as the red devil until a few years ago when a friend’s stepmother, undergoing treatment, used the term in an email. She’s a woman who read lots of blogs and shared her experiences with other breast cancer patients on–line. I realized that despite working in an academic medical center and regularly communicating with physician-friends and oncologists at meetings, I still had a few things to learn.

Now that I’m writing about cancer,I wonder what sorts of information people really want or need to make informed decisions. I suppose some would like to know the chemical structure of doxorubicin before receiving such a potentially poisonous, possibly life-saving drug. Maybe a patient’s husband, or daughter, would seek details about the half-life, metabolism in the liver, side effects and more.

When I received my chemotherapy, I didn’t want to read about breast cancer or treatments. Rather, I chose an oncologist I trusted and liked. Then, for the most part, I followed her advice. But this sort of strategy’s not for everyone, particularly for patients who don’t know their doctors as I knew mine. Besides, most cancer patients aren’t already board-certified oncologists.

With so much available data at our fingertips, some patients will amass many resources about their condition. Others will be more passive, mainly listening to their physicians or perhaps, to friends and family members who do the “research“ on their behalf. To a large extent, it’s a matter of personality –

Ultimately, you can’t know everything about Adriamycin until you’ve had it in your veins. Whether being familiar with the chemical structure makes a difference, is less certain.

What’s clear is this: with so much information at our disposal, there’s an opportunity for patients to help doctors make better decisions.